Questionnaire

Questionnaire

Please print out this questionnaire, answer the questions and bring with you to your first session.

 

Name: _____________________________________

 

Address: ___________________________________

___________________________________________

___________________________________________

___________________________________________

Post Code: __________________________________

 

Mobile: _____________________________________

Telephone number: ____________________________

Email: ______________________________________

 

Occupation: __________________________________

Date of birth: _________________________________

 

Medical Conditions

Please indicate and diagnosed medical problems you have

  • Diabetes
  • High Blood Pressure
  • Low Blood Pressure
  • Heart Disease
  • Cancer
  • Epilepsy
  • Arthritis
  • Migraines
  • Asthma
  • Anaemia 

Other (please specify) _________________________

___________________________________________

___________________________________________

 

 

 

 

 

Reasons for seeking Treatment

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

 

Health Background

Do you have any metal fillings?  Y  /  N

Are you currently taking any medications?  Y  /  N

         If Yes what are they for: ___________________

         _______________________________________

         _______________________________________

Have you ever had an injury to or fallen onto your coccyx?  Y  /  N

Have you ever had reconstructive dental work performed?  Y  /  N

Have you had any of your wisdom teeth removed?  Y  /  N

Do you experience 'clicking' in your jaw?  Y  /  N

Have you had any organs removed?  Y  /  N

        If Yes what organ(s): _______________________

        ________________________________________

Do you have any confirmed food allergies / intolerances?  Y  /  N

       If Yes which foods: _________________________

       _________________________________________

Do you suffer from hayfever?  Y  /  N

Do you have any digestive disturbances / symptoms?  Y  /  N

       If Yes please indicate: _______________________

       _________________________________________

       _________________________________________

 

Women only

Are you currently pregnant?  Y  /  N

Have you had a baby in the past 3 months?  Y  /  N

 

The information given about my health is accurate to best of my knowledge. If any new relevant health/medical related information comes to light in the future I will inform the practitioner at my next session.

Name: _______________________________________

Date: ________________________________________

 

 

 

 

 

 

 

 

 

 

Disclaimer

If you feel that you have an illness or disease, it is always recommended that you see your GP

Tests performed during a session are not able to provide a diagnosis, only a qualified medical doctor can diagnose an illness or disease

Treatments performed during a session are not intended to treat illnesses or diseases

Treatments performed during a session are not intended to replace medical treratments

I sign to confirm that I have read and understood the above disclaimer:

Name: ______________________________________

Date: _______________________________________

 

Recording

Sessions are recorded for the protection of both client and practitioner

Please sign to concent to being recorded at sessions

Name: _______________________________________

Date: ________________________________________

 

Muscle Testing & Bowen Technique

Sessions will combine Bowen Technique and Muscle Testing/Kinesiology

Please sign to confirm that you understand that sessions will employ a combination of these two techniques

Name: _______________________________________

Date: ________________________________________